Spontaneous miscarriage in the first trimesterBMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7552.1223 (Published 25 May 2006) Cite this as: BMJ 2006;332:1223
All rapid responses
Weeks and Danielsson1 concluded in their editorial that the high
failure rate of medical management of first trimester miscarriage in the
MIST trial2 was due to too early assessment of success after
administration of misoprostol. Participants were assessed 8 hours after
misoprostol was administered in this trial and the failure rate for early
fetal loss was
In our unit, for early fetal loss up to 9 weeks gestation, women receive
200mg of mifepristone and return to the unit 36-48 hours later for a
single vaginal administration of 800 microgram of misoprostol. All women
at this visit also receive prophylactic antibiotics (1 gm azithromycin and
1 gm metronidazole single dose). Women are counselled what to expect
subsequently, are given the contact details of the unit and are allowed
home. They are reviewed 2 weeks later in the unit. For fetal loss of >9
weeks, an extended regime of misoprostol is used and such women are kept
in till the fetal tissues are expelled or a maximum of four doses of
misoprostol have been given. I f the fetal tissues are not expelled after
4 doses of misoprostol, they are allowed home and reviewed 2 weeks later.
Over a 2-year period we had 34 cases of early fetal/embryonic loss. Women
diagnosed as having retained product of conception or incomplete
miscarriage at the first assessment were not included in this cohort. 23
of these 34 were up to 9 weeks gestation and the remaining 11 10-19 weeks.
Surgical evacuation was required in 2 - one in each category. Hence,
failure rate of the medical management in our women up to 9 weeks was 4.3%
and above 9 weeks was 9.1%. We had one woman of 12 weeks gestation who was
admitted with heavy bleeding and was managed conservatively. There was no
documented case of gynaecological infection or transfusion within 2 weeks
of misoprostol administration. Based on our experience, we believe that
review of the success of the medical management of early fetal/embryonic
loss can safely be deferred to the 2 weeks follow-up.
When counselling women on the management options of early fetal/embryonic
loss in our unit, based on the above data we quote a success rate of 90%
with the medical management.
1 Weeks A, Danielsson KG. Spontaneous miscarriage in the first
BMJ 2006;332: 1223-4.
2 Trinder J, Brocklehurst P, Porter R, Read M, Vyas S, Smith L. Management
of miscarriage: expectant, medical, or surgical? Results of randomised
controlled trial (miscarriage treatment (MIST) trial). BMJ 2006;332: 1235-
Competing interests: No competing interests